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Exercise-induced ST-segment depression in inferior leads during treadmill exercise testing and coronary artery disease
International Journal of Cardiology 145 (2010) e88 – e91 www.elsevier.com/locate/ijcard
Letter to the Editor
Exercise-induced ST-segment depression in inferior leads during treadmill exercise testing and coronary artery disease Salvatore Patanè a,⁎, Filippo Marte a , Giuseppe Dattilo a , Rosario Grassi b , Francesco Patanè c a
Cardiologia Nuovo Presidio Ospedaliero Cutroni Zodda-Barcellona P.d.G(Me) AUSL5 Messina, Via Cattafi 98051, Barcellona Pozzo di Gotto, Messina, Italy b Cardiologia Azienda Ospedaliera Papardo Messina (Me), Italy c Cardiochirurgia Azienda Ospedaliera Papardo Messina (Me), Italy Received 24 October 2008; accepted 14 December 2008 Available online 26 January 2009
Abstract The exercise electrocardiogram is a commonly used non-invasive and inexpensive method for detection of electrocardiogram (ECG) changes secondary to myocardial ischemia. Reversible ST-segment depression is the characteristic finding associated with exercise-induced, demand-driven ischemia in patients with significant coronary obstruction but no flow limitation at rest. The exercise-induced ST-segment depression in inferior leads has been questioned and it has been reported that lead V5 alone consistently outperforms the inferior leads and the combination of lead V5 with II, because lead II has a high false-positive rate. A review of the 12-lead visual electrocardiographic interpretations confirmed that changes isolated to the inferior leads were rare in patients, who had no diagnostic Q waves. Considering the sum of ST-segment depression or the most depression in the three leads representing the three main areas of the myocardium (II, V2, and V5) did not improve the diagnostic capacity of the test. A case is presented to illustrate how in a patient, the ST-segment depression in inferior leads during exercise testing is related with significant coronary artery disease. We present a case of exercise-induced ST-segment depression in inferior leads in a 52 year-old Italian man. This experience demonstrates that ST-segment depression in inferior leads during the exercise testing can have a diagnostic significance. © 2008 Elsevier Ireland Ltd. All rights reserved. Keywords: Coronary artery disease; Exercise testing; Inferior leads; ST segment depression
1. Case report The exercise electrocardiogram is a commonly used noninvasive and inexpensive method [1] for detection of electrocardiogram (ECG) changes secondary to myocardial ischemia.[2–5] Reversible ST-segment depression is the characteristic finding associated with exercise-induced, demand-driven ischemia in patients with significant coronary obstruction but no flow limitation at rest [6] and it has been reported that the diagnostic and prognostic power of ST segment depression limited to the recovery phase of an exercise test is also largely similar to that of ST segment ⁎ Corresponding author. Tel.: +393402783962. E-mail address: [email protected] (S. Patanè). 0167-5273/$ - see front matter © 2008 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2008.12.163
depression induced during effort. [7] Despite the well-known limitations, the exercise test continues to have substantial diagnostic and prognostic value when measures beyond simple ST-segment depression are considered and integrated with heart rate adjustment of the ST-segment depression, measurement of QRS duration and amplitude, QT- and T-wave changes, and ST-recovery loops and hysteresis. [6] The exercise-induced ST-segment depression in inferior leads has been questioned and it has been reported that lead V5 alone consistently outperforms the inferior leads and the combination of lead V5 with II, because lead II has a high false-positive rate. In patients without prior myocardial infarction and with normal resting ECG, the precordial leads alone are a reliable marker for coronary artery disease, and monitoring of inferior limb leads adds little additional diagnostic information. In
S. Patanè et al. / International Journal of Cardiology 145 (2010) e88–e91
patients with a normal resting ECG, exercise-induced STsegment depression confined to the inferior leads is of little value for identification of coronary disease. [8–12] Moreover, a review of the 12-lead visual electrocardiographic interpretations confirmed that changes isolated to the inferior leads were rare in patients, who had no diagnostic Q waves. Considering the sum of ST-segment depression or the most depression in the three leads representing the three main areas of the myocardium (II, V2, and V5) did not improve the diagnostic capacity of the test. [13] A case is presented to illustrate how in a patient, the ST-segment depression in inferior leads during exercise testing is related with significant coronary artery disease. We present a case of exercise-induced ST-segment depression in inferior leads in a 52 year-old Italian man. On October 9, 2008, a 52 year-old Italian man was admitted to the
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Cardiology Unit complaining of chest pain. A history of lipid disorders in treatment and a history of prior, but not current, smoking were present. Blood pressure values were 130/ 70 mmHg, the heart rate was 70 bpm, the oxygen saturation was normal. The ECG showed mild ST alterations in avl lead and an incomplete right bundle branch block. (Fig. 1 Panel A). Trop I was negative. C-reactive protein was 0.72 mg/l (normal value 0–5 mg/l), cholesterol was 222 mg/dl (normal value b200 mg/dl), triglycerides were 256 mg/dl (normal value 40– 170 mg/dl) , glycated haemoglobin concentration was 5.5% (normal value 4.5–5.7%). Echocardiographic evaluation revealed no alterations. On October 10, 2008, a treadmill exercise testing was performed. The first Ecg (at rest) showed T-on avL lead and an incomplete right bundle branch block. (Fig. 2 Panel A). At 3.05 of exercise the Ecg showed ST-
Fig. 1. Panel A: The admission ECG showed mild STalterations in avl lead and an incomplete right bundle branch block. Panels B and C: Coronary angiography revealed a non-significant left anterior descending coronary artery stenosis(30%), a non-significant circumflex coronary artery stenosis (30–40%) and a significant first diagonal proximal occlusion. Panel D: Right coronary artery at coronary angiography.
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S. Patanè et al. / International Journal of Cardiology 145 (2010) e88–e91
Fig. 2. Panel A: Ecg (at rest) showed T-on avL lead and an incomplete right bundle branch block. Panel B: At 3.05 of exercise the Ecg showed ST-segment depression on II III avF leads. Panel C: At 3.50 of exercise the Ecg showed ST-segment depression on II III avF leads and a mild ST depression on v3 lead. Panel D: At 1.21 of the recovery phase the Ecg showed ST-segment depression on II III avF leads and a mild ST-segment depression on v3 v4 v5 leads.
segment depression on II III avF leads. (Fig. 2 Panel B). At 3.50 of exercise the Ecg showed ST-segment depression on II III avF leads and mild ST-segment depression on v3 lead (Fig. 2 Panel C) and the test was interrupted because the patient complained chest pain. At 1.21 of the recovery phase the Ecg showed ST-segment depression on II III avF leads and a mild ST-segment depression on v3 v4v5 leads. (Fig. 1 Panel D) Successively, the exercise induced alterations disappeared during the recovery phase. Coronary angiography (Fig. 2 Panels B, C and D) revealed a non-significant left anterior descending coronary artery stenosis(30%), a non-significant circumflex coronary artery stenosis (30–40%) and a significant first diagonal proximal occlusion. Percutaneous transluminal coronary angioplasty with implantation of stent was successfully performed. In conclusion, this experience demonstrates that ST-segment depression in inferior leads during the exercise testing can have a diagnostic significance. Acknowledgement The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology [14].
References [1] Hayashino Y, Shimbo T, Tsujii S, et al. Cost-effectiveness of coronary artery disease screening in asymptomatic patients with type 2 diabetes and other atherogenic risk factors in Japan: factors influencing on international application of evidence-based guidelines. Int J Cardiol May 16 2007;118(1):88–96. Electronic publication 2006 Sep 1. [2] Lipton JA, Warren SG, Broce M, et al. High-frequency QRS electrocardiogram analysis during exercise stress testing for detecting ischemia. Int J Cardiol Feb 29 2008;124(2):198–203. Electronic publication 2007 Apr 25. [3] Palmieri V, Pezzullo S, Arezzi E, et al. Cycle-ergometry stress testing and use of chronotropic reserve adjustment of ST depression for identification of significant coronary artery disease in clinical practice. Int J Cardiol Jul 21 2008;127(3):390–2. Electronic publication 2007 Jun 21. [4] Johansen OE, Bjurö T, Endresen K, et al. Heart rate adjustments and analysis of recovery patterns of ST-segment depression in type 2 diabetes. Int J Cardiol Jun 23 2008;127(1):129–32. Electronic publication 2007 May 25. [5] Higgins JP, Higgins JA. Electrocardiographic exercise stress testing: an update beyond the ST segment. Int J Cardiol Apr 4 2007;116(3): 285–99. Electronic publication 2006 Jul 11. Review. [6] Kligfield P, Lauer MS. Exercise electrocardiogram testing: beyond the ST segment. Circulation Nov 7 2006;114(19):2070–82 Review. [7] Lanza GA, Mustilli M, Sestito A, Infusino F, Sgueglia GA, Crea F. Diagnostic and prognostic value of STsegment depression limited to the recovery phase of exercise stress test. Heart Dec 2004;90(12):1417–21.
S. Patanè et al. / International Journal of Cardiology 145 (2010) e88–e91 [8] Miranda CP, Liu J, Kadar A, et al. Usefulness of exercise induced ST segment depression in the inferior leads during exercise testing as a marker for coronary artery disease. Am J Cardiol 1992;69(4):303–7. [9] Gibbons RJ, Balady GJ, Beasley JW, et al. ACC/AHA guidelines for exercise testing: executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Exercise Testing). Circulation Jul 1 1997;96(1):345–54. [10] Gibbons RJ, Balady GJ, Beasley JW, et al. ACC/AHA guidelines for exercise testing: a report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines (Committee on Exercise Testing). J Am Coll Cardiol 1997;30:260–315. [11] Gibbons RJ, Balady GJ, Bricker JT, et al. American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Committee to Update the 1997 Exercise Testing Guidelines. ACC/AHA 2002 guideline update for exercise testing: summary article. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to
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Update the 1997 Exercise Testing Guidelines). J Am Coll Cardiol Oct 16 2002;40(8):1531–40. [12] Gibbons RJ, Balady GJ, Bricker JT, et al. American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing Guidelines). ACC/ AHA 2002 guideline update for exercise testing: summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing Guidelines). Circulation Oct 1 2002;106(14):1883–92. [13] Froelicher VF, Lehmann KG, Thomas R, et al. The electrocardiographic exercise test in a population with reduced workup bias: diagnostic performance, computerized interpretation, and multivariable prediction. Veterans Affairs Cooperative Study in Health Services #016 (QUEXTA) Study Group. Quantitative Exercise Testing and Angiography. Ann Intern Med Jun 15 1998;128:965–74 (12 Pt 1). [14] Coats AJ. Ethical authorship and publishing. Int J Cardiol 2009;131: 149–50.
Letter to the Editor
Exercise-induced ST-segment depression in inferior leads during treadmill exercise testing and coronary artery disease Salvatore Patanè a,⁎, Filippo Marte a , Giuseppe Dattilo a , Rosario Grassi b , Francesco Patanè c a
Cardiologia Nuovo Presidio Ospedaliero Cutroni Zodda-Barcellona P.d.G(Me) AUSL5 Messina, Via Cattafi 98051, Barcellona Pozzo di Gotto, Messina, Italy b Cardiologia Azienda Ospedaliera Papardo Messina (Me), Italy c Cardiochirurgia Azienda Ospedaliera Papardo Messina (Me), Italy Received 24 October 2008; accepted 14 December 2008 Available online 26 January 2009
Abstract The exercise electrocardiogram is a commonly used non-invasive and inexpensive method for detection of electrocardiogram (ECG) changes secondary to myocardial ischemia. Reversible ST-segment depression is the characteristic finding associated with exercise-induced, demand-driven ischemia in patients with significant coronary obstruction but no flow limitation at rest. The exercise-induced ST-segment depression in inferior leads has been questioned and it has been reported that lead V5 alone consistently outperforms the inferior leads and the combination of lead V5 with II, because lead II has a high false-positive rate. A review of the 12-lead visual electrocardiographic interpretations confirmed that changes isolated to the inferior leads were rare in patients, who had no diagnostic Q waves. Considering the sum of ST-segment depression or the most depression in the three leads representing the three main areas of the myocardium (II, V2, and V5) did not improve the diagnostic capacity of the test. A case is presented to illustrate how in a patient, the ST-segment depression in inferior leads during exercise testing is related with significant coronary artery disease. We present a case of exercise-induced ST-segment depression in inferior leads in a 52 year-old Italian man. This experience demonstrates that ST-segment depression in inferior leads during the exercise testing can have a diagnostic significance. © 2008 Elsevier Ireland Ltd. All rights reserved. Keywords: Coronary artery disease; Exercise testing; Inferior leads; ST segment depression
1. Case report The exercise electrocardiogram is a commonly used noninvasive and inexpensive method [1] for detection of electrocardiogram (ECG) changes secondary to myocardial ischemia.[2–5] Reversible ST-segment depression is the characteristic finding associated with exercise-induced, demand-driven ischemia in patients with significant coronary obstruction but no flow limitation at rest [6] and it has been reported that the diagnostic and prognostic power of ST segment depression limited to the recovery phase of an exercise test is also largely similar to that of ST segment ⁎ Corresponding author. Tel.: +393402783962. E-mail address: [email protected] (S. Patanè). 0167-5273/$ - see front matter © 2008 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2008.12.163
depression induced during effort. [7] Despite the well-known limitations, the exercise test continues to have substantial diagnostic and prognostic value when measures beyond simple ST-segment depression are considered and integrated with heart rate adjustment of the ST-segment depression, measurement of QRS duration and amplitude, QT- and T-wave changes, and ST-recovery loops and hysteresis. [6] The exercise-induced ST-segment depression in inferior leads has been questioned and it has been reported that lead V5 alone consistently outperforms the inferior leads and the combination of lead V5 with II, because lead II has a high false-positive rate. In patients without prior myocardial infarction and with normal resting ECG, the precordial leads alone are a reliable marker for coronary artery disease, and monitoring of inferior limb leads adds little additional diagnostic information. In
S. Patanè et al. / International Journal of Cardiology 145 (2010) e88–e91
patients with a normal resting ECG, exercise-induced STsegment depression confined to the inferior leads is of little value for identification of coronary disease. [8–12] Moreover, a review of the 12-lead visual electrocardiographic interpretations confirmed that changes isolated to the inferior leads were rare in patients, who had no diagnostic Q waves. Considering the sum of ST-segment depression or the most depression in the three leads representing the three main areas of the myocardium (II, V2, and V5) did not improve the diagnostic capacity of the test. [13] A case is presented to illustrate how in a patient, the ST-segment depression in inferior leads during exercise testing is related with significant coronary artery disease. We present a case of exercise-induced ST-segment depression in inferior leads in a 52 year-old Italian man. On October 9, 2008, a 52 year-old Italian man was admitted to the
e89
Cardiology Unit complaining of chest pain. A history of lipid disorders in treatment and a history of prior, but not current, smoking were present. Blood pressure values were 130/ 70 mmHg, the heart rate was 70 bpm, the oxygen saturation was normal. The ECG showed mild ST alterations in avl lead and an incomplete right bundle branch block. (Fig. 1 Panel A). Trop I was negative. C-reactive protein was 0.72 mg/l (normal value 0–5 mg/l), cholesterol was 222 mg/dl (normal value b200 mg/dl), triglycerides were 256 mg/dl (normal value 40– 170 mg/dl) , glycated haemoglobin concentration was 5.5% (normal value 4.5–5.7%). Echocardiographic evaluation revealed no alterations. On October 10, 2008, a treadmill exercise testing was performed. The first Ecg (at rest) showed T-on avL lead and an incomplete right bundle branch block. (Fig. 2 Panel A). At 3.05 of exercise the Ecg showed ST-
Fig. 1. Panel A: The admission ECG showed mild STalterations in avl lead and an incomplete right bundle branch block. Panels B and C: Coronary angiography revealed a non-significant left anterior descending coronary artery stenosis(30%), a non-significant circumflex coronary artery stenosis (30–40%) and a significant first diagonal proximal occlusion. Panel D: Right coronary artery at coronary angiography.
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S. Patanè et al. / International Journal of Cardiology 145 (2010) e88–e91
Fig. 2. Panel A: Ecg (at rest) showed T-on avL lead and an incomplete right bundle branch block. Panel B: At 3.05 of exercise the Ecg showed ST-segment depression on II III avF leads. Panel C: At 3.50 of exercise the Ecg showed ST-segment depression on II III avF leads and a mild ST depression on v3 lead. Panel D: At 1.21 of the recovery phase the Ecg showed ST-segment depression on II III avF leads and a mild ST-segment depression on v3 v4 v5 leads.
segment depression on II III avF leads. (Fig. 2 Panel B). At 3.50 of exercise the Ecg showed ST-segment depression on II III avF leads and mild ST-segment depression on v3 lead (Fig. 2 Panel C) and the test was interrupted because the patient complained chest pain. At 1.21 of the recovery phase the Ecg showed ST-segment depression on II III avF leads and a mild ST-segment depression on v3 v4v5 leads. (Fig. 1 Panel D) Successively, the exercise induced alterations disappeared during the recovery phase. Coronary angiography (Fig. 2 Panels B, C and D) revealed a non-significant left anterior descending coronary artery stenosis(30%), a non-significant circumflex coronary artery stenosis (30–40%) and a significant first diagonal proximal occlusion. Percutaneous transluminal coronary angioplasty with implantation of stent was successfully performed. In conclusion, this experience demonstrates that ST-segment depression in inferior leads during the exercise testing can have a diagnostic significance. Acknowledgement The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology [14].
References [1] Hayashino Y, Shimbo T, Tsujii S, et al. Cost-effectiveness of coronary artery disease screening in asymptomatic patients with type 2 diabetes and other atherogenic risk factors in Japan: factors influencing on international application of evidence-based guidelines. Int J Cardiol May 16 2007;118(1):88–96. Electronic publication 2006 Sep 1. [2] Lipton JA, Warren SG, Broce M, et al. High-frequency QRS electrocardiogram analysis during exercise stress testing for detecting ischemia. Int J Cardiol Feb 29 2008;124(2):198–203. Electronic publication 2007 Apr 25. [3] Palmieri V, Pezzullo S, Arezzi E, et al. Cycle-ergometry stress testing and use of chronotropic reserve adjustment of ST depression for identification of significant coronary artery disease in clinical practice. Int J Cardiol Jul 21 2008;127(3):390–2. Electronic publication 2007 Jun 21. [4] Johansen OE, Bjurö T, Endresen K, et al. Heart rate adjustments and analysis of recovery patterns of ST-segment depression in type 2 diabetes. Int J Cardiol Jun 23 2008;127(1):129–32. Electronic publication 2007 May 25. [5] Higgins JP, Higgins JA. Electrocardiographic exercise stress testing: an update beyond the ST segment. Int J Cardiol Apr 4 2007;116(3): 285–99. Electronic publication 2006 Jul 11. Review. [6] Kligfield P, Lauer MS. Exercise electrocardiogram testing: beyond the ST segment. Circulation Nov 7 2006;114(19):2070–82 Review. [7] Lanza GA, Mustilli M, Sestito A, Infusino F, Sgueglia GA, Crea F. Diagnostic and prognostic value of STsegment depression limited to the recovery phase of exercise stress test. Heart Dec 2004;90(12):1417–21.
S. Patanè et al. / International Journal of Cardiology 145 (2010) e88–e91 [8] Miranda CP, Liu J, Kadar A, et al. Usefulness of exercise induced ST segment depression in the inferior leads during exercise testing as a marker for coronary artery disease. Am J Cardiol 1992;69(4):303–7. [9] Gibbons RJ, Balady GJ, Beasley JW, et al. ACC/AHA guidelines for exercise testing: executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Exercise Testing). Circulation Jul 1 1997;96(1):345–54. [10] Gibbons RJ, Balady GJ, Beasley JW, et al. ACC/AHA guidelines for exercise testing: a report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines (Committee on Exercise Testing). J Am Coll Cardiol 1997;30:260–315. [11] Gibbons RJ, Balady GJ, Bricker JT, et al. American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Committee to Update the 1997 Exercise Testing Guidelines. ACC/AHA 2002 guideline update for exercise testing: summary article. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to
e91
Update the 1997 Exercise Testing Guidelines). J Am Coll Cardiol Oct 16 2002;40(8):1531–40. [12] Gibbons RJ, Balady GJ, Bricker JT, et al. American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing Guidelines). ACC/ AHA 2002 guideline update for exercise testing: summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing Guidelines). Circulation Oct 1 2002;106(14):1883–92. [13] Froelicher VF, Lehmann KG, Thomas R, et al. The electrocardiographic exercise test in a population with reduced workup bias: diagnostic performance, computerized interpretation, and multivariable prediction. Veterans Affairs Cooperative Study in Health Services #016 (QUEXTA) Study Group. Quantitative Exercise Testing and Angiography. Ann Intern Med Jun 15 1998;128:965–74 (12 Pt 1). [14] Coats AJ. Ethical authorship and publishing. Int J Cardiol 2009;131: 149–50.